Infection Control Lapses Seen in Surgicenters

Action Points

Explain to interested patients that about two-thirds of ambulatory surgical centers had lapses in infection control during a pilot inspection program in three states.

Further explain that the results of these inspections may not be generalizable to all ambulatory surgical centers in the U.S.

Failure to follow recommendations to control nosocomial infections appears to be common in ambulatory surgical centers -- even during formal inspections, researchers found.

Of 68 centers in three states participating in a pilot inspection program, about two-thirds (67.6%) had a lapse in at least one of five infection control categories, according to Melissa Schaefer, MD, of the CDC's Division of Healthcare Quality Promotion in Atlanta, and colleagues.

The most common problems occurred in the handling and cleaning of blood glucose monitoring equipment (46.3%), injection safety and medication handling (28.4%), and the reprocessing of surgical equipment (28.4%), the researchers reported in the June 9 issue of the Journal of the American Medical Association.

"Findings from the pilot inspections ... demonstrate that potentially serious breaches in infection control have been occurring in ambulatory surgical centers in multiple states," Schaefer and colleagues wrote.

"[These] centers are performing increasingly complex procedures and the volume of procedures performed in these facilities continues to increase as healthcare shifts to outpatient settings," they continued. "Thus, a parallel increase in emphasis and resource allocation toward infection control ... is warranted."

Currently, more than 5,000 ambulatory surgical centers participate in Medicare. These centers performed more than six million procedures in 2007, but little is known about infection control at such facilities.

In 2008, there was a major outbreak of hepatitis C virus infection at an ambulatory surgical center in Las Vegas that highlighted the issue of infection control at these centers.

The outbreak resulted in statewide inspections using a CDC-developed infection control audit tool that uncovered problems in 28 of 51 centers.

This prompted the Centers for Medicare & Medicaid Services (CMS) to start a pilot inspection program in three states -- Maryland, North Carolina, and Oklahoma -- randomly selecting 68 ambulatory surgical centers for inspection using the CDC audit tool.

CMS surveyors arrived unannounced, but personnel were notified that an inspection was taking place and that they would be observed.

Five categories of infection control were assessed. They were (with percentage of centers with lapses):

Hand hygiene and use of personal protective equipment: 19.4%

Injection safety and medication handling, including the use of single-dose vials for more than one patient: 28.4%

Equipment reprocessing, including reuse of single use instruments without propersterilization and high-level disinfection: 28.4%

Environmental cleaning, including the cleaning of high-touch surfaces in patient-care areas: 18.8%

Handling and cleaning of blood glucose monitoring equipment: 46.3%

Overall, about two-thirds of the centers inspected had a lapse in at least one category of infection control, and 17.6% failed in at least three.

There was no association between the presence of a lapse and the number of procedures performed or the type of facility, but only centers in Oklahoma had documented problems related to environmental cleaning.

In an accompanying editorial, Philip Barie, MD, MBA, of Weill Cornell Medical College in New York City, noted that individuals are expected to perform better when they know they are being observed, as was the case during these inspections.

"Poor performance or compliance with even the basics of infection control while aware of being under direct observation becomes all the more astonishing in [that] context," he wrote.

Ultimately, 57.4% of the centers were cited for deficiencies in infection control, and 29.4% were cited for problems with medication administration.

It appears that use of the CDC-designed audit tool may have increased the inspectors' attention to infection control because the number of centers with observed deficiencies (67.6%) was more than six-fold greater than the year before the inspections (8.2% for infection control and 9.2% for medication administration), said Schaefer and colleagues.

They acknowledged some limitations of the inspections and the analysis, including the fact that the evaluation was conducted at a single point in time and used a limited number of procedures or healthcare professionals.

In addition, patient outcomes and frequency of lapses were not measured, and variability in the knowledge and experience of the inspectors likely resulted in some differences among the three states.

Finally, the authors said the findings may not be generalizable to all ambulatory surgical centers.

But if they are generalizable, Barie commented, "then among the estimated more than six million patients who undergo procedures in [these centers] annually in the U.S., it is possible that several million patients could be at potential risk for healthcare-associated infections each year. This risk is not acceptable and must be corrected immediately and definitively."

Funding for the pilot ambulatory surgical center inspections was provided by the Centers for Medicare & Medicaid Services.

Schaefer did not make any financial disclosures. One of her co-authors reported owning stock in Pfizer, Eli Lilly, Monsanto, General Electric, and Walgreens.

Barie reported being a consultant to and receiving honoraria from AstraZeneca, Cadence, Eisai, Forest Laboratories, Eli Lilly, Merck, Novartis, Ortho McNeil-Janssen, and Pfizer, and grant support from Johnson & Johnson.

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